The NRA versus The Doctors: A Psychiatrist’s Take On an Explosive Issue

by Ronald Pies | June 20, 2011 8:47 PM EDT

My thanks to Tash Rose for reinforcing the point made by Susan Ward--that the Florida law could have an adverse effect on the safety of many thousands of mental health workers and clinicians who make home visits, evaluate families involved in domestic violence, etc. --Ron Pies MD

by Tash Rose | June 18, 2011 2:30 PM EDT

Wi
th reference to Susan Ward's comment, in Australia working as a Community Mental Health Nurse I was involved in assessing an independent elderly man living alone, presumably suffering from untreated depression. It was a routine call-out, a referral from a physician requesting an initial in-home assessment. No Hx or mention of fire-arms had been documented therefore questions of that nature asked at the door could understandably have been interpreted by the patient as being invasive, intrusive; it may have impacted on whether the assessment went ahead-in hind-sight though, it could have prevented a possible fatality.

There were no overt clinical signs of depression. Person invited myself in. It was only well into conversation when discussing any Hx of intent/plan/means to self harm that he said-in passing-that he had been out at the range all day-belonging to a rifle club/registered firearms etc
---Registered or illegal-as stated above-was not the issue---.

Asked about firearms being locked away and where; found firearms cupboard to be unlocked and open; stated-he was in process of cleaning same when i called and thought to show it to me-unloaded of course-as he now had it in his hands, continuing to clean-denying any suicidation whatsoever. He found the the situation amusing-I realized I'd walked into a power-play. Clinically depressed?..... Definitely some undesirable personality traits.

Had the physician questioned his patient with regards any intent to self harm? was there a plan? did he have the means to carry this out? Had I thought to clarify with the physician if the patient had access to firearms, as there was no reference to this in the referral letter?

Needless to say the incident became one of high importance in terms of occ/health and safety on RTW, Monday.
Policy and procedures r/t to every aspect of patient referrals for in-home assessment were reviewed......as was physician/nurse documentation.

Apologies for the extended comment on what is an anecdotal reference to an incident outside the US-not affected by the legislation discussed here. I guess I wanted to/or had a need to share-as a nurse-not a physician-what it is like on the front-line, in a person's home with unexpected fire-arms present: an unforgettable
learning ex
perience, one though that myself. the organization, the physician and hospital involved undoubtedly learned from.

by Ronald Pies | May 24, 2011 1:15 PM EDT

from Ron Pies, in reference to the Massachusetts Medical Society--

I am pleased to report the following development, following the annual MMS meeting last weekend:


"Delegates adopted a resolution [#405] that opposes legislative interference in the right of physicians and patients or parents and guardians to discuss gun ownership, storage or safety in the home. The resolution also opposes any legislative or regulatory limits on a physician's ability to take a complete history and document relevant portions of the history into the permanent medical record."

by Ronald Pies | May 16, 2011 1:07 AM EDT

An addendum to readers:

Psychiatric Times operates on the principle that readers leaving comments provide their real first and last names. Blackbeard the Pirate ("Edward Teach") seems an unlikely source of reliable information on forensic psychiatry. The relevant principle here, Edward, is called integrity.

Oh, yes--to the point about "information bias": obviously, merely inquiring about gun possession is not enough--taking appropriate action, commensurate with the clinical circumstances and risks, is also required. But if psychiatrists are cowed by Florida-type laws, they may not ask about firearms at all, and that will guarantee that, in many cases, no appropriate action will be taken. This is clearly no way to reduce our medico-legal liability.

Ronald Pies MD

by Ronald Pies | May 14, 2011 4:46 PM EDT

I appreciate the concerns expressed by Michael Ganz, Edward Teach, and William Sauve, but I believe that, in some instances, they have reached fallacious, and potentially dangerous, conclusions.

First: the use of a "reductio ad absurdum"argument, such as that offered by Michael Ganz, will not protect the physician in the event of a failure to assess the patient's risk of gun-related violence. Obviously, there are an infinite number of possible risk factors that increase the probability of suicide or homicide (Does the patient keep poisonous snakes in the house? Are there tall buildings with unprotected balconies in the neighborhood? etc.) but some risk factors are far more lethal than others, and are universally recognized as such within the medical/psychiatric profession. One of these is gun possession, as a risk factor in suicide, homicide, and combined suicide/homicide. For more on this, please see the article "Firearms and Mental Illness" in Psychiatric Times, by forensic psychiatrist Donna Norris MD and Marilyn Price MD, Oct. 30, 2009). As these clinicians state:
"Access to firearms is an important factor for clinicians to consider in any risk assessment of suicidal patients. Miller and Hemenway report that "in 2005, an average of 46 Americans a day committed suicide with a firearm, accounting for 53% of all completed suicides."…All discussions with the patient and his or her family regarding firearms should be documented. When clinicians are doing a psychiatric examination of suicidal patients, they should inquire about the availability of firearms in the household. If a firearm is available, concerns about safety should be raised with the family and police. This is particularly true when children and adolescents reside in the household."

Regarding Edward Teach's claim that "…the [Florida] law reduces physician liability, not increases it…"-a sort of "If we don't ask, and they don't tell, the law will say that all is well" argument--I believe this reflects a misunderstanding of how litigation against physicians works in this country. Of course, in the end, physicians often "win" a frivolous law suit, based on various legal arguments-but that doesn't stop plaintiffs from initiating law suits and dragging the physician through the courts, even if the MD defendant ultimately prevails.

Now, to be clear: the current formulation of the Florida law does permit inquiries re: firearms when "…the information is relevant to the patient's medical care or safety or the safety of others…" That exception may sound quite reasonable, and evidently, it persuaded the Florida Medical Association, who ultimately went along with the bill. But the "exception" clause has not persuaded many Florida pediatricians, who believe such a law would still have a chilling effect on the thoroughness of the doctor's evaluation. According to National Public Radio

http://www.npr.org/2011/05/07/136063523/florida-bill-could-muzzle-doctors-on-gun-safety

one specialist in adolescent medicine recently told a Florida Senate committee, "What if I have an adolescent who's been bullied, [but] who's not suicidal? I don't think, under the current bill, I'm entitled to ask him if there's a gun in the home, or if he's carried a gun to school, or if he's thinking of harming someone else with a gun."

Indeed, the "relevance" clause may actually put the psychiatrist/physician in a medico-legal "double bind". If he or she fails to inquire about gun possession because it is not deemed "relevant", and the patient goes on to commit some act of gun-related violence, the physician may be held liable for failing to ask the "relevant" questions. On the other hand, if the physician decides that a query about gun possession is relevant; but the patient believes otherwise and becomes angry about the "invasion of privacy", he or she could initiate a suit against the doctor, on the grounds that the gun possession query was not clinically "relevant".

To put it bluntly: the physician should not be constantly looking over his or her shoulder at how much legal risk is entailed in asking clinically-indicated questions about firearms! Obviously, the "gun" question will not come up when a patient presents in the ER with a sore throat, any more than an astute physician would do a rectal exam under such circumstances. But these judgments should be dictated by our medical training, not by misguided legislation that intrudes on the physician's freedom of speech, as well as on the privacy of the doctor-patient relationship. That "the patient-physician relationship has already been inappropriately invaded" and has become "an arm of social policy" is no argument for a law that merely worsens our profession's predicament. --Ronald Pies MD